Injuries to the face may result in fractures of the facial skeleton. If unrepaired, these fractures sometimes lead to long-term deformity or asymmetry of the underlying bone structure, or a functional deficit affecting the ability to breath, eat and see.

If you have sustained a facial fracture, you should be evaluated by a facial plastic and reconstructive surgeon. Following a careful examination and review of CT scans, your surgeon will discuss your options and together you may decide upon your optimal treatment plan.

Nasal Fractures

Nasal bone fractures are the most common of all facial fractures. The nasal bones are located in the upper third of the nose and connect with the middle vault cartilages to form the nasal dorsum.

Nasal bones that are fractured but have not moved out of their natural place are often left to heal on their own, without requiring surgical manipulation. However, if a nasal bone fracture results in bones that have moved, when they heal, a significant deformity may result. Within a certain window of opportunity, a closed reduction or “resetting” of the nasal fracture may be performed to straighten the nose without invasive surgery.

Sometimes a closed reduction or “resetting” will not achieve the ideal benefits of improved appearance and function. If this is the case, after a waiting period of time for healing, a rhinoplasty may be considered. A rhinoplasty offers improved precision in addressing functional and aesthetic concerns.

Cheekbone Fractures

Fractures of the cheekbone (referred to as “Malar fractures,” “ZMC fractures,” or “tripod fractures”) are extremely common after injuries to the face. The fracture often causes numbness along the cheek and upper teeth and may be associated with either swelling or a depression over the cheek.

If a cheekbone fracture is suspected, your surgeon will carefully examine the area and review your CT scan before discussing with you whether your fracture is best treated with or without surgery. A cheekbone fracture that is aligned well can sometimes be treated without surgery, and bone union will take place in approximately 6 weeks time (granted no further injuries occur). If the fractured segment is misaligned, however, surgery may be recommended.

The goals of surgical repair for a displaced cheekbone fracture are to expose the fractured bone in the most aesthetic and least invasive way, to reduce the fractured bone back into its natural position and to fixate the bone with very thin, strong, titanium hardware. Every consideration is made by our surgeons to hide the incisions in areas that cannot be seen after healing, such as within the mouth or hairline. Our surgeons use minimally invasive techniques when appropriate to help our patients return to normal activity as fast as possible and with the least visible scar.

Cheekbone fractures often accompany orbital fractures, or injuries to the bones supporting the eye. These bones are thin, and if fractured, they may not provide the eye with proper support. If not properly repaired, over time, the eye may sink down and double vision may result. For these reasons, careful evaluation of the orbital bones, the function of the eye and the CT scan are required to develop a proper care plan for these types of fractures.

Jaw Fractures

Fractures of the jaw (mandible) are common after injury to the lower part of the face. Jaw fractures are often accompanied by pain with chewing, a feeling of the teeth being misaligned and numbness along one side of the chin and lower lip. As with other facial fractures, a thorough exam and review of CT scans is needed if a jaw fracture is suspected.

Depending on the severity and location of the fracture, treatment may range from simple restriction to a soft diet to surgery involving placement of thin, strong titanium hardware. Every attempt is made to minimize the number of incisions, to hide incisions in the mouth and to minimize the chance of jaw wiring.

Forehead Fractures

Although the forehead is quite strong, a blow to this region may result in varying degrees of injury to the underlying bone. Above the nose and in the center of the forehead lies an air filled space called the “frontal sinus.” Further behind this area is the brain. Injuries to this region may involve the frontal bone, back bone or traverse further back towards the brain. The long-term health and ability for the frontal sinus to function properly must be considered with this fracture pattern. Reconstruction for these fractures involves hiding an incision in the hair to reconstruct any bony deformity that may have resulted, while ensuring the health of the sinus. At Mass. Eye and Ear, our facial plastic and reconstructive surgeons collaborate with sinus surgeons to offer the best possible treatment plan for forehead fractures involving the sinuses.

Correction of a saddle nose deformity

Saddle nose deformities make the nose appear “scooped” from the side view and wide on the frontal view. In addition, patients with saddle nose often have severe nasal obstruction. The nasal deformity and nasal obstruction both occur because of a lack of support of the septum. Saddle nose deformities are most often caused by a fractured septum that can no longer provide support to the bridge of the nose. In other cases, they are caused by a septal perforation(large hole in the septum.)

Saddle nose deformities may be corrected by rebuilding the structural support that was lost by the trauma or the perforation. The surgeon may use a cartilage graft from the ear or the rib if needed. The goal of nasal reconstruction for saddle nose deformity is to improve nasal breathing and to create a straight nasal bridge.

Nasal reconstruction after Mohs surgery and removal of skin cancer

Removal of skin cancer lesions, especially in the delicate areas of the head and neck, may impact both the function and appearance of the nose. The goal of nasal reconstruction after Mohs surgery is to create a nose that is as close to the preoperative appearance as possible, while also ensuring proper nasal function.
A variety of reconstructive techniques may be used to restore nasal function and to create an aesthetic result, depending upon the size and location of the defect. Your surgeon will work with you to determine the best reconstructive option.

The "H" zone: facial areas commonly affected by skin cancer.

Reconstructive Techniques for Nasal Repair after Mohs Surgery

Primary Closure

For small defects on the nose in cases where the skin may be brought together easily without distorting the normal anatomy.

Skin Grafts

For lesions that are too large for primary closure a skin graft may be used. The skin graft is usually taken from behind the ear or then sutured into the area of the defect. The disadvantage of skin grafts (especially on the nose) is that the color and thickness of the skin graft may not perfectly match the skin on the nose. Your surgeon will discuss the risks and benefits with you in more detail.

Local Flaps

Local flaps are the most common method for repairing defects on the nose. This technique allows surgeons to repair the defect with skin of similar color and thickness as the skin that was removed. Occasionally, a small piece of cartilage from the ear is also needed to restore the shape and function of the nose.

Pedicled Flaps

For large nasal defects, a pedicled flap is often recommended to provide the best cosmetic and functional result. This type of reconstruction requires at least two procedures. The first procedure is usually performed in the main operating room under sedation or general anesthesia for patient comfort, and the second procedure is usually performed under local anesthesia. You and your surgeon will decide what is best for you.

For pedicled flaps, the surgeon reconstructs the nose using skin from the forehead or the cheek with the skin’s native blood supply. The transferred skin is still dependent upon its native blood supply for many weeks after surgery. Once the transferred skin has developed a new blood supply from the surrounding skin, the native blood supply is no longer needed. At this point, the second procedure is performed to divide the native blood supply and to contour the nose. Sometimes another procedure is needed to thin the skin of the flap before the native blood supply is cut.

A pedicled flap is a complex reconstructive procedure. Further details of the surgery will be discussed with your surgeon during your consultation.

Secondary Procedures

The reconstructive surgeon’s goal is to provide patients with a nose that is as close to their old nose as possible. We follow our patients closely after surgery, and if we note that redness or a thickened scar may be developing, we may recommend scar massage or small doses of steroid injections to break down the scar as it forms. If the scar is reddened, we may prescribe a special bandage to wear at night. For persistent redness that does not respond to topical treatment, we also have the option to refer patients to our Laser Center.

Scars on the face can be noticeable and a distraction to daily communication. For some, scars may be an unsightly reminder of a previous injury and they may limit the function of daily activities such as eating, breathing and speaking. Frequently people wish to have their scars revised to not only improve their aesthetic appearance, but also their ability to function.

Once a scar forms, it is permanent; however, there are surgical and non-surgical techniques available to make a scar less visible, either by surgically relocating it or by minimizing its prominence. Mass. Eye and Ear offers the services of highly trained dermatologists and facial plastic and reconstructive surgeons to ensure that every opportunity is available to revise scars in the best possible manner.

Scar Treatment Techniques

Different types of scars often require different treatments. Because scars are highly individual, some may require more than one procedure and multiple techniques.

Steroid Injections

Steroids may be injected directly into the scar tissue to decrease the size of the scar and to alleviate any itching, redness and/or burning sensations. Steroid injections are often used in conjunction with surgery, and the injections may be continued for up to two years after the surgery to maximize healing and to prevent recurrence.

Laser Resurfacing

Laser resurfacing makes rough or elevated scars less prominent by removing part of the upper layers of skin with laser light. This technique may be used alone or in combination with surgical excision. Though most scars heal after excision without needing any further intervention, the laser can be helpful in those scars where redness (erythema) and/or elevation of the excision site have developed.

Excision

Primary excision of a scar is often a first consideration in surgical scar management. The scar tissue is excised and the skin edges are re-approximated with great precision, so the wound edges heal in a more favorable way than they did in the past.

Furthermore, long and prominent scars can be “broken up” or irregularized. This technique makes the resulting scar less visible to the eye, as multiple shorter segments replace one longer one.

Skin Flap

Skin flap procedures may be performed after scar tissue excision to further minimize the scar’s appearance. Adjacent, healthy skin is lifted and moved to form a new incision line.

Skin Graft

When a flap is not possible, a skin graft may be used. A graft involves taking a section of skin tissue from one area and attaching it to another. Time must be allowed following surgery for new blood vessels and soft tissue to form.

Z-plasty

Z-plasty is a method of scar relocation, usually moving the scar into a natural fold or skin crease with the aim to minimize its visibility. While Z-plasties do not remove all signs of a scar, it does make it less noticeable during daily communication.

Tissue Expansion

Tissue expansion is a technique used for scars that cover very large surface areas. Tissue expansion involves the placement of an expanding device that is slowly infused with saline over time, to stretch the overlying skin. When the device is removed, the additional tissue is then used to cover an area of large scar. This technique is often used in conjunction with skin flap surgery for large scars.

A scar should be analyzed with respect to its location, functional restrictions, and aesthetic location in the context of each individual patient. Then a comprehensive management plan for the scar can be developed to minimize its visibility.

If you would like a consultation to review the options for improvement in your scar, please call our Division of Facial Plastic and Reconstructive Surgery at 617-573-3223 to schedule an appointment with one of our physicians.

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